Community Care Licensing

Document Has Been Signed on 09/12/2023 05:33 PM - It Cannot Be Edited

FACILITY NAME:	LE ELEN MANOR, INC		FACILITY NUMBER:	490108263
ADMINISTRATOR:	GUEVARRA, ANTHONY		FACILITY TYPE:	735
ADDRESS:	5522 OLD REDWOOD HWY		TELEPHONE:	(707) 569-9478
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 20		CENSUS: 20	DATE:	09/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Janet Hermogenes-Administrator Back-up		TIME COMPLETED:	05:40 PM

SUPERVISORS NAME: Hope DeBenedetti LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023

FACILITY NAME: LE ELEN MANOR, INC	FACILITY NUMBER: 490108263
	VISIT DATE: 09/12/2023

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR, INC	FACILITY NUMBER: 490108263
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

Type A

Section Cited

CCR

85087(b)

(b) Stairways, inclines, ramps, open porches, and areas of potential hazard to clients whose balance or eyesight is poor shall not be used by clients unless such areas are well lighted and equipped with sturdy hand railings. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPAs observed two unrailed cement ramps that lead into sight-impaired resident's unit; resident uses a folding blind walking stick. Currently, the ramps have ropes strung across, which are not secure or sturdy. The cement ramps are a hazard as it lacks no hand rails or safety barriers for the resident, the licensee did not comply with the section cited above in [2] out of [2] ramps which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit plan on installing hand and side rails on both/two ramps by 9/13/23. Completion of hand and side rails are to be complete by 10/27/2023. Follow-up to POC, Submit photos and how ramps were made sturdy and safe for residents in care.

Type A

Section Cited

CCR

80088(e)(3)

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA's observed 3 out of 5 full bathrooms to have floors covered in mud and dirt, heavily strong urine odor, feces odor, unflushed urine and feces in toilet., the licensee did not comply with the section cited above in [3] out of [5]) bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee stated to the LPAs that all three of the bathrooms will be renovated; Licensee to submit renovation plan by 9/13/23. Completion of the three bathrooms to be completed by 10/27/2023. Follow-up to POC, Submit photos and how bathrooms were renovated.

SUPERVISOR'S NAME: Carla Martinez LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR, INC	FACILITY NUMBER: 490108263
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

Type A

Section Cited

CCR

85088(c)

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPAs observed heavily soiled towels hanging in bathrooms used by multiple residents], the licensee did not comply with the section cited above in [3] out of [5) bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/13/2023
	Plan of Correction
1 2 3 4	Licensee to ensure all clients in care have access and use of clean and sanitary linens, including hand and bathing towels. Licensee to submit plan of correction and supply of clean linen for each residents use. POC due by 9/13/23..

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Carla Martinez LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR, INC	FACILITY NUMBER: 490108263
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

Type B

Section Cited

CCR

80021(a)(2)

(2) Subsequent to initial licensure, the licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients, but no less frequently than specified in the following table: For a licensed capacity of 6 or fewer analysis is required at initial licensing and subsequent analysis is not required unless evidence supports the need for such analysis to protect clients. For a licensed capacity of 7 through 15 analysis is required at initial licensing and subsequent analysis is required annually. For a licensed capacity of 16 through 24 analysis is required at initial licensing and subsequent analysis is required semiannually. For a licensed capacity of 25 or more analysis is required at initial licensing and subsequent analysis is required quarterly. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per file reviews, required semi-annual water bacterial analysis not completed, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients, Submit copy of the water bacteriological analysis report to Licensing by 10/13/23. POC due 10/13/23.

SUPERVISOR'S NAME: Carla Martinez LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR, INC	FACILITY NUMBER: 490108263
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

Type B

Section Cited

CCR

80088(b)

(b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPAs observed facility window screens throughout the property to be torn, covered in dirt and cobwebs and/or missing the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/13/2023
	Plan of Correction
1 2 3 4	Licensee to submit plan on repairing screens on all windows and/or installing new screens by 10/13/2023. Completion of all facility window screens being cleaned and repaired/replaced are to be complete by 10/13/2023. Submit plan of how deficiency was cleared and photos of windows with repaired/replcaed screens by 10/13/23.

Type B

Section Cited

CCR

80020(a)

(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPAs were provided a Santa Rosa Fire Department(SRFD) Report of an inspection conducted on 9/11/23, which stated there were violations to codes 604.5, 605.3.1, 903.1, 901.6, and 603.4.1, the licensee did not comply with the section cited above in the most recent SRFD inspection on 9/11/23, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Licensee to bring all violations noted into compliance. SRFD is requesting Licensee to forward corrections to them and/or SRFD is returning to reinspect the areas noted in their report. LPA obtained a copy of SRFD inspection report.. POC due 10/12/23.

SUPERVISOR'S NAME: Carla Martinez LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR, INC	FACILITY NUMBER: 490108263
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/12/2023

Type B

Section Cited

HSC

1565(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per file reviews, facility quarterly drills were not conducted, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/06/2023
	Plan of Correction
1 2 3 4	Licensee to submit plan of correction on how the facility will ensure to hold quarterly drills as required by Health & Safety Code. Submit POC by 10/6/23.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Carla Martinez LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2023